The Issue
High-income countries face the daunting challenge of managing health and social care budgets. This problem is made more difficult by the fact that a small percentage of patients with complex needs account for a significant share of spending. But the challenge also presents an opportunity for countries to learn to better manage budgets by integrating health and social care services for high-cost patients.
In a study in Health Affairs, researchers supported by the Commonwealth Fund looked at 30 integrated health and social care programs in Australia, Canada, France, Germany, the Netherlands, Norway, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States. They categorized policy supports into four areas: governance and partnerships, workforce and staffing, financing and payment, and data-sharing and use.
Integrated health and social care models often focused on creating multidisciplinary teams and expanding the roles or providers.
What the Study Found
- Twenty-three of the programs were supported by new governance policies. Many programs adopted steering committees; for instance, a Swiss program was managed by a steering committee of local care providers, health insurance companies, and public authorities. In New Zealand, programs emphasized partnerships between general practices and nongovernmental organizations (NGOs), and across NGOs, particularly those led by Maori people.
- New approaches to staffing or work roles were a feature in 27 programs. Models often focused on creating multidisciplinary teams and expanding the roles or providers. In France, for instance, advance practice nurses can take on tasks previously performed by physicians, like screening or patient education.
- Just over half (18) of the programs identified financing or payment policy changes. In some cases, this involved centralized solutions like creating new budgets to cover the full cost of all health and social care services for high-need patients. Germany, the Netherlands, and the United States all have innovative programs that used such bundled budgets. Alternatively, there was experimentation with flexible, local financing. A respondent in New Zealand reported a program that created a local discretionary fund to cover pharmacy copayments and passes to swimming pools to encourage exercise.
- Only half (15) of the programs had data-sharing as a key program feature. This typically took the form of allowing one clinical group (e.g., a hospital or primary care practice) to have access to the clinical records of another group. A few programs used rigorous external evaluators to manage data and report on outcomes.
The Big Picture
Respondents from nearly all programs reported that two or more new policy approaches were important to program development and spread, suggesting that providing better-integrated care requires policy changes at many levels. The authors said they found a mix of national or central policy supports and local or institutional supports. Overall, their analysis suggests that combining top-down or national approaches (e.g., changing workforce regulations) with local or bottom-up approaches (e.g., empowering local organizations to work together) may be the best way to support innovation.
The Bottom Line
Policymakers should consider a hybrid top-down, bottom-up approach to support integrated care, which may be particularly effective in bringing together previously siloed sectors.
